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Cardiovascular/ PACES/Station No.

Contents A. B. C. D. E. F. G. Skills tested List of Cases Common signs in a Cardiovascular case Mnemonics for murmurs Common Viva questions in Cardiology case for the PACES exam Samples available on the web Useful links

A. Skills tested
Skills tested include ; a. Physical examination b. Identifying physical signs c. Differential diagnosis d. Clinical judgment e. Maintaining patient welfare

B. List of Cases

This can be generally divided into four categories. a. Most common cases b. The hijacker c. Spot diagnosis d. Less common cases a. Most common cases 1. Postoperative 2. Native valve lesions 3. Septal defects 1. Postoperative These include; a. Prosthethic valves ( Aortic, Mitral and both Aortic and Mitral) 2. Native valve lesions These include; a. Isolated valve lesions. For example, MS,MR,AS,AR b. Mixed valve lesions such as MS/MR , AS/AR and and combination of these. 3. Septal defects VSD with coarctation of aorta and TOF b. The hijacker is dextrocardia c. Spot diagnosis include Down's syndrome, Marfan's syndrome and Ankylosing spondylitis. d. Less common cases include; Irregular and slow pulse Raised JVP List of cases recommended by Pastest include; 1. Aortic valve replacement 2. Mitral valve replacement 3. Aortic and mitral valve replacement 4. VSD with coarctation of aorta

5. Aortic stenosis 6. Aortic regurgitation 7. Mixed aortic valve disease 8. Mitral stenosis 9. Mitral regurgitation 10. Mixed mitral valve disease 11. Combination of aortic and mitral valve disease 12. Mitral valve prolapse 13. Leaking metallic valve 14. Marfan's syndrome 15. VSD 16.Kartagener's syndrome

C. Common signs in a Cardiovascular case

List of common physical signs a. General inspection b. Hands and pulse c. Neck d. Palpation e. Auscultation f. Evidence of decompensation a. General inspection Breathlessness Down's Mitral facies Marfans's Cyanosis Neck veins Thoracotomy scars Peripheral oedema Scars on legs from previous surgery for example CABG b. Hands and Pulses Perfusion, clubbing, stigmata of endocarditis, normal pulse, irregularly-irregular pulse, slow rising pulse, collapsing pulse,radio-radial and radio-femoral delay. c. Neck JVP ( cannon waves, "V" waves), Corrigan's sign. Goiter. d. Palpation Absent apex beat ( dextrocardia), thrusting and tapping apex beat, parasternal heave. e. Auscultation 1. Clicks and murmurs of prosthetic heart valves 2. Native valves murmurs

3. Abnormal Heart sounds 1. Clicks and murmurs of prosthetic heart valves Prosthetic mitral valve clicks Prosthetic aortic valve clicks Double valve replacements clicks Multiple clicks Early diastolic murmur of leaking aortic valve Ejection systolic murmur of normal aortic valve Pansystolic murmur of normal mitral valve prosthesis 2. Native valves murmurs Pansystolic murmur of mitral regurgitation Mid-diastolic murmur of MS Mid-systolic click which may or may not be followed by a systolic murmur in Mitral valve prolapse Ejection systolic murmur of Aortic stenosis Early diastolic murmur of aortic regurgitation Diastolic murmur of pulmonary insufficiency Pansystolic murmur of tricuspid regurgitation and VSD. 3. Abnormal Heart sounds Soft first sound of MR Loud first sound of MS Isolated mid-systolic click of mitral valve prolapse Absent heart sounds on left side in dextrocardia Soft aortic component of AS Splitting of second heart sound in PS and ASD 3rd and 4th heart sounds F. Evidence of decompensation Crepitations in lungs Sacral oedema Peripheral oedema

D. Mnemonics for murmurs

1. Dr. Mostafa Ahmed: Pansystolic murmure have nice mnemonic =MTV which is mitral regurgitation, tricuspid regurgitation, VSD 2. . Dr. Paarth Sharma : PASS =Pulmonary aortic stenosis systolic murmur and PAID=Pulmonary aortic insufficiency diastolic 3. . Dr. Zeeshan Syed: All named murmers are diastolic like graham steel...carey coomb...austin flint 4. . Dr.Faraz Mansoor: HUMTV(HAMTV) is a famous Pakistani drama channel ( systolic murmurs) HOCM, Aortic stenosis, Mitral regurgitation, Tricuspid regurgitation, VSD. And murmurs which are heard best on changing the patient's positions are diastolic such as Mitral stenosis and Aortic regurgitation

E. Common Viva questions


1. What are the complications of prosthetis heart valves ? 2. How would you routinely follow up a patient with a prosthetic heart valve ? 3. Which valve has the greatest propensity for thrombosis ? 4. What are the indications of urgent valve repl acement in Aortic stenosis ? 5. How long a prosthetic heart valve last ? 6. What is the rough mortality in prosthetic valve endocarditis ? 7. What is the rough perioperative mortality in heart valve surgery ? 8. What are the causes of aortic stenosis ? 9. What are the causes of aortic regurgitation 10. What are the causes of mitral stenosis ? 11. What are the causes of mitral regurgitation ? 12. How will you investigate valvular heart disease ? 13. What are the symptoms of a leaking prosthetic valve ? 14. What questions will you ask from a patient with a prosthetic heart valve on his/her routine OPD visit ? 15. What are the causes of anemia in a patient with a prosthetic heart valve ? 16. What are the chest x ray findings in coarctation of aorta ? 17. What are signs of coarctation of aorta ? 18. What are the reasons for a radio-femoral delay and systolic murmur in a patient with corrected coarctation of aorta ? 19. What are the indications of surgery in AS.AR,MS,MR ? 20. How will you assess severity in AS,AR,MS,MR ? 21. How will you differentiate aortic sclerosis from aortic stenosis? 22. Aortic stenosis vs aortic regurgitation ? 23. What is the prevalence of mitral valve prolapse in general population ? 24. What are the cardiac and skeletal manifestations of Marfan's syndrome ? 25. How will you manage AF in a patient with MS ? 26. What is the correct timing of surgery in MS ? 27. Endocarditis prophylaxis ?

H. Sample Cases available on the web


For sample cases that are available on the web, presently. Please click on the links below.

Heart Sounds
1. Normal heart sounds http://www.youtube.com/watch?v=xS3jX1FYG-M&feature=BFa&list=ULPsmGx2XMxF8 2. Aortic Stenosis http://www.youtube.com/watch?v=Gbk2465HO98&feature=channel&list=UL 3. Aortic Regurgitation http://www.youtube.com/watch?v=42IahK-zxj0&feature=BFa&list=ULGbk2465HO98 4. Mitral Stenosis http://www.youtube.com/watch?v=L5DEqvgS_xs&feature=BFa&list=UL42IahK-zxj0 5. Mitral Regurgitation http://www.youtube.com/watch?v=MMJBSd5Z_Uc&feature=BFa&list=ULL5DEqvgS_xs 6. Pulmonary Stenosis http://www.youtube.com/watch?v=SWW1PTL9Jbw&feature=BFa&list=ULMMJBSd5Z_Uc 7. Tricuspid Regurgitation http://www.youtube.com/watch?v=Jk50shI9vV8&feature=BFa&list=ULSWW1PTL9Jbw 8. Midsystolic click http://www.youtube.com/watch?v=PsmGx2XMxF8&feature=BFa&list=ULJk50shI9vV8

Sample exam cases


1. Basic cardiovascular examination http://www.youtube.com/watch?v=dp5m2tXHDmA&feature=share

2. Mitral Valve Regurgitation http://www.youtube.com/watch?v=wQpMT6b4nvM&feature=plcp

3. Mitral valve prolapsed http://www.youtube.com/watch?v=zsH9PNVBBG8&feature=plcp 4. Mitral Stenosis http://www.youtube.com/watch?v=TMGhiTlN9aM&feature=plcp 5. Mitral Regurgitation http://www.youtube.com/watch?v=0g3Q9iJfi0U&feature=plcp http://www.youtube.com/watch?v=AWYSp2o0tyY&feature=plcp 6. Mixed aortic valve disease http://www.youtube.com/watch?v=PIZBP1ocf4Q&feature=plcp http://www.youtube.com/watch?v=C76JUGFo1Mw&feature=plcp 7. Mitral prosthesis with AF http://www.youtube.com/watch?v=H4OPsBHqpdE&feature=plcp 8. Mitral and aortic valve prosthesis http://www.youtube.com/watch?v=CR5X2bXS4rY&feature=plcp 9. Leaking Mitral valve prosthesis http://www.youtube.com/watch?v=zAIhr10v_Jw&feature=plcp 10. Aortic regurgitation http://www.youtube.com/watch?v=l2hE996CKCg&feature=plcp http://www.youtube.com/watch?v=RWt-LsTJHVQ&feature=plcp 11. Mixed aortic and mitral valve disease http://www.youtube.com/watch?v=ZiSoSXtOrOU&feature=plcp

12. Aortic stenosis http://www.youtube.com/watch?v=xxMC2fDCyiA&feature=plcp http://www.youtube.com/watch?v=tRCmovqYOxw&feature=plcp 13. Aortic and mitral regurgitation http://www.youtube.com/watch?v=DK_2PS9Gudc&feature=plcp 14. Marfans syndrome http://www.youtube.com/watch?v=d49spJ-2XmY&feature=plcp 15. Mitral prosthesis http://www.youtube.com/watch?v=wQpMT6b4nvM&feature=plcp 16. Aortic prosthesis http://www.youtube.com/watch?v=zfx8VPNV1S4&feature=plcp http://www.youtube.com/watch?v=8Pv25P_bSdA&feature=plcp

Other Signs
1. Left parasternal heave http://www.youtube.com/watch?v=02tTNP2lmGU 2. Apex beat http://www.youtube.com/watch?v=W0k_IgbYx-c 3. Cannon wave http://www.youtube.com/watch?v=gMBZMQwoi_I 4. V wave http://www.youtube.com/watch?v=ceX3KmZCZhY 5. Corrigans sign http://www.youtube.com/watch?v=C6mTmpP9Lvw 6. Quinckes pulse http://www.youtube.com/watch?v=S5iEMu

F. Useful Links
1. 2012 ESC guidelines http://www.escardio.org/guidelines-surveys/escguidelines/GuidelinesDocuments/Guidelines_Valvular_Heart_Dis_FT.pdf 2. European Society of Cardiology Homepage http://www.escardio.org/Pages/index.aspx 3. European Society of Intensive Care Medicine Homepage http://www.esicm.org/ 4. Uptodate homepage http://www.uptodate.com/index 5. Cochrane Homepage http://www.cochrane.org/ 6. National Institute and Clinical Excellence Homepage ( NICE) http://www.nice.org.uk/